|
COCR HEMI HEAD 60M OD MED NECK
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
COCR HEMI HEAD 60M OD MED NECK
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
COCR HEMI HEAD 60M OD SHT NECK
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
COCR HEMI HEAD 60M OD SHT NECK
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
CODA BALLOON CATH 10.0-35-120-
|
Facility
|
OP
|
$3,563.75
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
27000014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,069.12 |
| Max. Negotiated Rate |
$3,421.20 |
| Rate for Payer: Aetna Commercial |
$2,744.09
|
| Rate for Payer: Anthem Medicaid |
$1,225.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,779.72
|
| Rate for Payer: Cash Price |
$1,781.88
|
| Rate for Payer: Cigna Commercial |
$2,957.91
|
| Rate for Payer: First Health Commercial |
$3,385.56
|
| Rate for Payer: Humana Commercial |
$3,029.19
|
| Rate for Payer: Humana KY Medicaid |
$1,225.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,238.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,922.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,630.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,069.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,250.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,136.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,672.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,851.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,100.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,458.99
|
| Rate for Payer: PHCS Commercial |
$3,421.20
|
| Rate for Payer: United Healthcare All Payer |
$3,136.10
|
|
|
CODA BALLOON CATH 10.0-35-120-
|
Facility
|
IP
|
$3,563.75
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
27000014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,069.12 |
| Max. Negotiated Rate |
$3,421.20 |
| Rate for Payer: Aetna Commercial |
$2,744.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,779.72
|
| Rate for Payer: Cash Price |
$1,781.88
|
| Rate for Payer: Cigna Commercial |
$2,957.91
|
| Rate for Payer: First Health Commercial |
$3,385.56
|
| Rate for Payer: Humana Commercial |
$3,029.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,922.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,630.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,069.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,136.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,672.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,851.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,100.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,458.99
|
| Rate for Payer: PHCS Commercial |
$3,421.20
|
| Rate for Payer: United Healthcare All Payer |
$3,136.10
|
|
|
CODA BALLOON CATH 10.0-35-140-
|
Facility
|
IP
|
$4,355.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
27000014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,306.50 |
| Max. Negotiated Rate |
$4,180.80 |
| Rate for Payer: Aetna Commercial |
$3,353.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,396.90
|
| Rate for Payer: Cash Price |
$2,177.50
|
| Rate for Payer: Cigna Commercial |
$3,614.65
|
| Rate for Payer: First Health Commercial |
$4,137.25
|
| Rate for Payer: Humana Commercial |
$3,701.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,571.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,213.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,306.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,832.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,266.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,484.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,788.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,004.95
|
| Rate for Payer: PHCS Commercial |
$4,180.80
|
| Rate for Payer: United Healthcare All Payer |
$3,832.40
|
|
|
CODA BALLOON CATH 10.0-35-140-
|
Facility
|
OP
|
$4,355.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
27000014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,306.50 |
| Max. Negotiated Rate |
$4,180.80 |
| Rate for Payer: Aetna Commercial |
$3,353.35
|
| Rate for Payer: Anthem Medicaid |
$1,497.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,396.90
|
| Rate for Payer: Cash Price |
$2,177.50
|
| Rate for Payer: Cigna Commercial |
$3,614.65
|
| Rate for Payer: First Health Commercial |
$4,137.25
|
| Rate for Payer: Humana Commercial |
$3,701.75
|
| Rate for Payer: Humana KY Medicaid |
$1,497.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,512.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,571.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,213.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,306.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,527.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,832.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,266.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,484.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,788.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,004.95
|
| Rate for Payer: PHCS Commercial |
$4,180.80
|
| Rate for Payer: United Healthcare All Payer |
$3,832.40
|
|
|
CODA BALLOON CATH 32 120 SHAFT
|
Facility
|
OP
|
$4,208.75
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
27000014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,262.62 |
| Max. Negotiated Rate |
$4,040.40 |
| Rate for Payer: Aetna Commercial |
$3,240.74
|
| Rate for Payer: Anthem Medicaid |
$1,447.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,282.82
|
| Rate for Payer: Cash Price |
$2,104.38
|
| Rate for Payer: Cigna Commercial |
$3,493.26
|
| Rate for Payer: First Health Commercial |
$3,998.31
|
| Rate for Payer: Humana Commercial |
$3,577.44
|
| Rate for Payer: Humana KY Medicaid |
$1,447.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,462.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,451.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,106.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,262.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,476.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,703.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,156.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,367.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,661.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.04
|
| Rate for Payer: PHCS Commercial |
$4,040.40
|
| Rate for Payer: United Healthcare All Payer |
$3,703.70
|
|
|
CODA BALLOON CATH 32 120 SHAFT
|
Facility
|
IP
|
$4,208.75
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
27000014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,262.62 |
| Max. Negotiated Rate |
$4,040.40 |
| Rate for Payer: Aetna Commercial |
$3,240.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,282.82
|
| Rate for Payer: Cash Price |
$2,104.38
|
| Rate for Payer: Cigna Commercial |
$3,493.26
|
| Rate for Payer: First Health Commercial |
$3,998.31
|
| Rate for Payer: Humana Commercial |
$3,577.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,451.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,106.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,262.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,703.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,156.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,367.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,661.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.04
|
| Rate for Payer: PHCS Commercial |
$4,040.40
|
| Rate for Payer: United Healthcare All Payer |
$3,703.70
|
|
|
CODEINE 15mg Tablet
|
Facility
|
OP
|
$60.72
|
|
|
Service Code
|
NDC 54024324
|
| Hospital Charge Code |
25004184
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.22 |
| Max. Negotiated Rate |
$58.29 |
| Rate for Payer: Aetna Commercial |
$46.75
|
| Rate for Payer: Anthem Medicaid |
$20.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.36
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Cigna Commercial |
$50.40
|
| Rate for Payer: First Health Commercial |
$57.68
|
| Rate for Payer: Humana Commercial |
$51.61
|
| Rate for Payer: Humana KY Medicaid |
$20.88
|
| Rate for Payer: Kentucky WC Medicaid |
$21.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.43
|
| Rate for Payer: Ohio Health Group HMO |
$45.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.90
|
| Rate for Payer: PHCS Commercial |
$58.29
|
| Rate for Payer: United Healthcare All Payer |
$53.43
|
|
|
CODEINE 15mg Tablet
|
Facility
|
IP
|
$60.72
|
|
|
Service Code
|
NDC 54024324
|
| Hospital Charge Code |
25004184
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.22 |
| Max. Negotiated Rate |
$58.29 |
| Rate for Payer: Aetna Commercial |
$46.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.36
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Cigna Commercial |
$50.40
|
| Rate for Payer: First Health Commercial |
$57.68
|
| Rate for Payer: Humana Commercial |
$51.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.43
|
| Rate for Payer: Ohio Health Group HMO |
$45.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.90
|
| Rate for Payer: PHCS Commercial |
$58.29
|
| Rate for Payer: United Healthcare All Payer |
$53.43
|
|
|
CODFISH IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000734
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
CODFISH IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000734
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
COENZYME Q10 100MG CAPSULE
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 87701040816
|
| Hospital Charge Code |
25000439
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
COENZYME Q10 100MG CAPSULE
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 87701040816
|
| Hospital Charge Code |
25000439
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
COGENTIN (BENZTROPINE 1MG/1TAB
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
25000440
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
COGENTIN (BENZTROPINE 1MG/1TAB
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
25000440
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
COGENTIN (BENZTROPINE) 2MG/2ML
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
25001888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$315.84 |
| Rate for Payer: Aetna Commercial |
$253.33
|
| Rate for Payer: Anthem Medicaid |
$113.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.62
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$273.07
|
| Rate for Payer: First Health Commercial |
$312.55
|
| Rate for Payer: Humana Commercial |
$279.65
|
| Rate for Payer: Humana KY Medicaid |
$113.14
|
| Rate for Payer: Kentucky WC Medicaid |
$114.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.52
|
| Rate for Payer: Ohio Health Group HMO |
$246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.01
|
| Rate for Payer: PHCS Commercial |
$315.84
|
| Rate for Payer: United Healthcare All Payer |
$289.52
|
|
|
COGENTIN (BENZTROPINE) 2MG/2ML
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
25001888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$315.84 |
| Rate for Payer: Aetna Commercial |
$253.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.62
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$273.07
|
| Rate for Payer: First Health Commercial |
$312.55
|
| Rate for Payer: Humana Commercial |
$279.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.52
|
| Rate for Payer: Ohio Health Group HMO |
$246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.01
|
| Rate for Payer: PHCS Commercial |
$315.84
|
| Rate for Payer: United Healthcare All Payer |
$289.52
|
|
|
COGNITIVE EVAL EA HR
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
HCPCS 96125
|
| Hospital Charge Code |
44000017
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna Commercial |
$117.04
|
| Rate for Payer: Anthem Medicaid |
$52.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.56
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$126.16
|
| Rate for Payer: First Health Commercial |
$144.40
|
| Rate for Payer: Humana Commercial |
$129.20
|
| Rate for Payer: Humana KY Medicaid |
$52.27
|
| Rate for Payer: Kentucky WC Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.76
|
| Rate for Payer: Ohio Health Group HMO |
$114.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.88
|
| Rate for Payer: PHCS Commercial |
$145.92
|
| Rate for Payer: United Healthcare All Payer |
$133.76
|
|
|
COGNITIVE EVAL EA HR
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
HCPCS 96125
|
| Hospital Charge Code |
44000017
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna Commercial |
$117.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.56
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$126.16
|
| Rate for Payer: First Health Commercial |
$144.40
|
| Rate for Payer: Humana Commercial |
$129.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.76
|
| Rate for Payer: Ohio Health Group HMO |
$114.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.88
|
| Rate for Payer: PHCS Commercial |
$145.92
|
| Rate for Payer: United Healthcare All Payer |
$133.76
|
|
|
COLACE (DOCSATE SOD 100MG/10ML
|
Facility
|
IP
|
$9.85
|
|
|
Service Code
|
NDC 121187000
|
| Hospital Charge Code |
25000442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$9.46 |
| Rate for Payer: Aetna Commercial |
$7.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.68
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna Commercial |
$8.18
|
| Rate for Payer: First Health Commercial |
$9.36
|
| Rate for Payer: Humana Commercial |
$8.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.67
|
| Rate for Payer: Ohio Health Group HMO |
$7.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.80
|
| Rate for Payer: PHCS Commercial |
$9.46
|
| Rate for Payer: United Healthcare All Payer |
$8.67
|
|
|
COLACE (DOCSATE SOD 100MG/10ML
|
Facility
|
OP
|
$9.85
|
|
|
Service Code
|
NDC 121187000
|
| Hospital Charge Code |
25000442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$9.46 |
| Rate for Payer: Aetna Commercial |
$7.58
|
| Rate for Payer: Anthem Medicaid |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.68
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna Commercial |
$8.18
|
| Rate for Payer: First Health Commercial |
$9.36
|
| Rate for Payer: Humana Commercial |
$8.37
|
| Rate for Payer: Humana KY Medicaid |
$3.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.67
|
| Rate for Payer: Ohio Health Group HMO |
$7.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.80
|
| Rate for Payer: PHCS Commercial |
$9.46
|
| Rate for Payer: United Healthcare All Payer |
$8.67
|
|
|
COLACE (DOCUSATE SO 100MG/1CAP
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 904718361
|
| Hospital Charge Code |
25000441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
